A Better System for Preventative Care

Walking into Dental School, I knew I would change the world! Walking out, I had been trained to repair
teeth and make a great smile. Where was the disconnect?! My dental training was excellent, and my
Class II box is a work of art. Now that I look back over the better of two decades as a pediatric dentist,
there was very little discussion that the rest of the body is connected to and influenced by the mouth
and vice-versa. (28, 29, 30) After over a decade and a half of repairing teeth and paying lip service to
prevention, I was not able to stomach the thought of another restoration without addressing the
complete health of the child sitting in my chair. What could I do to take this child that was suffering from
oral disease and change their life without picking up a handpiece? I knew that if we wanted to truly
become preventive that we needed a better system.

Parents are frustrated and tired of repairing cavities in their children’s mouths. According to the CDC,
more than half of children six to eight years old have had at least one cavity in their primary teeth and
more than half of children from 12 to 19 years old have a cavity in their permanent teeth. (1) This
accounts for thirty-four million hours of school missed and an estimated forty-five billion dollars in lost
productivity in the workforce. (2) Children are unable to concentrate in school, sleep at night, etc., all of
which lead to unhealthy children that turn into unhealthy adults.(3,4) From the AAPD, “the
consequences of Early Childhood Caries often include a higher risk of new caries lesions in both the
primary and permanent dentitions, hospitalizations and emergency room visits, high treatment costs,
loss of school days, diminished ability to learn, and diminished oral health-related quality of life.” (5)

How do we move from a society that waits for disease to manifest to a society that prefers to manage
things before they create a problem? I love the phrase “the absence of disease is not health.”

The ADA has recognized that caries is a complex multifactorial disease where “Drill and Fill” is not
adequate for control (6,23). To address this, the advent of Caries Risk Assessment (CRA) has taken shape
over the years. On quick examination I found eighteen different CRA options all with varying criteria.
Featherstone’s research says that no one knows which is best, and predictably, the provider will have to
be the one that decides what to use and how. (7) In our office, to assess risk and prevent disease, we
incorporated the assessment we felt best fit our situation with an interesting modification (which
incidentally Featherstone alluded to). (8)

As a dental professional we were all taught the caries balance between protective and pathological
factors. Everything from buffer capacity and adequate saliva flow on one end, to cariogenic bacteria and
frequent carbohydrates on the other. Objective and subjective risk assessment items were the hurdle we
needed to cross. The subjective information would be everything the parent tells us, accurate or not!
The objective items were always the usual: recent restorations, white spots, etc. How do we impart this
information that shows risk for disease to a person that is not familiar with oral disease or is not
interested? That is where saliva testing in our facility came into play.

As a pediatric dentist I mainly deal with children. The difficult part for me is that children come with
baggage. They are called parents. Fortunately, most parents truly do want the best for their children, but
dentally they often do not know what that is. By showing data with actual measurements, or criteria, we
have been able to engage more parents/caregivers in a way that captured their attention.

The two methods we use involve either a swab of the lingual surface of the mandibular anteriors (for our
non-cooperative patients) or collecting a small volume of expectorated water. The swab gives us a
relative acid content of the plaque in that area, and the expectorated water shows relative levels of
cariogenic bacteria, acidity, buffer capacity, protein, blood, leukocytes, and ammonia. This shows
caregivers a number that takes a vague, nonspecific discussion into a more concrete discussion that 
opens doors we previously were not aware existed. We now have the option, especially with the
expectorant test, to discuss caries risk, inflammation, and relative biome content of the oral cavity and
how that can affect or is being affected by the rest of the body.

Let’s take a quick dive back into all those courses that most of us, barring the strange like myself, have
tried to forget! The microbiome of a child, depending on C-section or vaginal birth, and article you read,
will be similar to the parents during the first year to eighteen months of life. (9,10) Beyond the first year
we start to see deviation as more foods and epigenetics come into play. (11) Why are we waiting until
the parent, especially if they have an unhealthy oral microbiome, transfers that microbiome to the child?
(12) The AAPD recommends we see every child 6 months after the eruption of the first tooth or by age 1.
(31) That works great if we have parents that are healthy with a healthy microbiome feeding their child
the proper foods, etc. That also works if we have all the medical/dental providers providing the
necessary information to the parents at the appropriate times. We as a dental profession need to step
up and demand that to truly prevent future health issues plaguing both children and adults, these issues
are addressed before day one. (13)

Why are we not screening parents prenatally to try and alter what bacteria they are going to transfer to
the next generation? (14) As I do not have a consistent number of women who are pregnant coming to
my office, this screening will require a collaboration between pediatric and general dentists along with
pediatricians, obstetricians, and any other medical or dental provider that they come into contact with.
When we step outside the box, which we have created for ourselves, we will be able to screen for oral
inflammation which has been linked to low birth weight, premature labor, and other pregnancy issues.
(15) While the initial screening gives relative information on caries risk and inflammation, it is low cost
and gives results in less than five minutes. This information can catapult at-risk individuals into more
definitive testing for specific results and interventions.

With the subjective and objective clinical observations, along with salivary information, we have been
able to discuss risk, behavior, and track the progress of the interventions we are using. Each child we see
is unique, and in a unique situation, so placing a blanket prevention program does not work. (16)
With the conversation open and the discussion with parents taking more of a concrete approach, now
we can more effectively discuss the root issues that are causing the decay, inflammation, etc. Counseling
on diet, issues with salivary flow due to medications, nasal versus mouth breathing, inflammatory status
and sleep disordered breathing are just the start of where the conversations have now moved. Early
referral to pediatricians for children that are showing high inflammation in the salivary screening can
now be evaluated for obesity, prediabetes, SDB, UARS, and the list goes on. (17, 18, 19, 20, 21, 22, 24,
25) We now see traction with involving whole family discussions on diet modification to improve health
for the family unit versus focusing on single children. (26, 27) No longer does the phrase, “Grandma/
Grandpa/random person at the store gives them candy all the time” work.

I have heard the question, “Are you preventing yourself out of a job?” If only this were a real possibility!
Assume that we can completely eradicate decay. What would people do with that estimated forty-five
billion dollars in lost productivity? Realistically, we are just setting ourselves up to be the “go to” place for
oral and systemic health. I love the title that Kevin Boyd has coined: Primary Care Dentist. I also love the
idea from Next Level consulting that it’s not a recall but an Oral Health Assessment. Imagine this: Healthy
patients, Healthy practice. Besides, who doesn’t want to look back at the end and say “Wow, I did change
the world”.

1. Centers for Disease Control and Prevention. Vital signs: dental sealant use and untreated tooth
decay among US school-aged children. MMWR. 2016;65(41):1141-1145.
2. Nasseh K, Greenberg B, Vujicic M, Glick M. The effect of chairside chronic disease screenings by
oral health professionals on health care dollars. Am J Public Health. 2014;104(4):744–750.
3. Naavaal S, Kelekar U. School hours lost due to acute/unplanned dental care. Health Behav Policy
Rev. 2018;5(2);66–73.
4. Righolt AJ, Jevdjevic M, Marcenes W, Listl S. Global-, regional-, and country-level economic
impacts of dental diseases in 2015. J Dent Res. 2018;97(5):501–507.
5. American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Consequences
and preventive strategies. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2021:81-4.
6. The American Dental Association Caries Classification System for Clinical Practice Young, Douglas
A. Ekstrand, Kim R. et al. The Journal of the American Dental Association, Volume 146, Issue 2,
79 – 86
7. Featherstone, J.D.B.; Crystal, Y.O.; Alston, P.; Chaffee, B.W.; Doméjean, S.; Rechmann, P.; Zhan, L.;
Ramos-Gomez, F.A. Comparison of Four Caries Risk Assessment Methods. Front. Oral Health.
2021, 2, 656558.
8. Rechmann P, Chaffee BW, Rechmann BMT, Featherstone JDB. Caries Management by Risk
Assessment: Results from a Practice-Based Research Network Study. J Calif Dent Assoc. 2019
Jan;47(1):15-24. PMID: 30853771; PMCID: PMC6407860.
9. Kaan A, Kahharova D, Zaura E. The acquisition and establishment of the oral
microbiota. Periodontol 2000. 2021; 86(1): 113- 134.
10. Jo, R., Yama, K., Aita, Y. et al. Comparison of oral microbiome profiles in 18-month-old infants
and their parents. Sci Rep 11, 861 (2021)
11. Gaufin T, Tobin NH, Aldrovandi GM. The importance of the microbiome in pediatrics and
pediatric infectious diseases. Curr Opin Pediatr. 2018 Feb;30(1):117-124.
12. Sampaio-Maia B, Monteiro-Silva F. Acquisition and maturation of oral microbiome throughout
childhood: An update. Dent Res J (Isfahan). 2014 May;11(3):291-301. PMID: 25097637; PMCID:
PMC4119360.
13. Mueller NT, Bakacs E, Combellick J, Grigoryan Z, Dominguez-Bello MG. The infant microbiome
development: mom matters. Trends Mol Med. 2015 Feb;21(2):109-17. doi: 10.1016/
j.molmed.2014.12.002. Epub 2014 Dec 11. PMID: 25578246; PMCID: PMC4464665.
14. Weizhong Li, Terhi Tapiainen, Lauren Brinkac, Hernan A Lorenzi, Kelvin Moncera, Mysore V
Tejesvi, Jarmo Salo, Karen E Nelson, Vertical Transmission of Gut Microbiome and Antimicrobial
Resistance Genes in Infants Exposed to Antibiotics at Birth, The Journal of Infectious Diseases,
Volume 224, Issue 7, 1 October 2021, Pages 1236–1246
15. Yenen Z, Ataçağ T. Oral care in pregnancy. J Turk Ger Gynecol Assoc. 2019 Nov 28;20(4):264-268.
doi: 10.4274/jtgga.galenos.2018.2018.0139. Epub 2018 Dec 17. PMID: 30556662; PMCID:
PMC6883753.
16. Kisling LA, M Das J. Prevention Strategies. [Updated 2022 May 8]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
17. Alqaderi H, Hegazi F, Al-Mulla F, Chiu CJ, Kantarci A, Al-Ozairi E, Abu-Farha M, Bin-Hasan S,
Alsumait A, Abubaker J, Devarajan S, Goodson JM, Hasturk H, Tavares M. Salivary Biomarkers as 
Predictors of Obesity and Intermediate Hyperglycemia in Adolescents. Front Public Health. 2022
Jun 10; 10:800373. doi: 10.3389/fpubh.2022.800373. PMID: 35757631; PMCID: PMC9231680.
18. Soukup, M., Biesiada, I., Henderson, A. et al. Salivary uric acid as a noninvasive biomarker of
metabolic syndrome. Diabetol Metab Syndr 4, 14 (2012). https://doi.org/
10.1186/1758-5996-4-14
19. Goodson JM, Kantarci A, Hartman M-L, Denis GV, Stephens D, Hasturk H, et al. (2014) Metabolic
Disease Risk in Children by Salivary Biomarker Analysis. PLoS ONE 9(6): e98799. https://doi.org/
10.1371/journal.pone.0098799
20. Vaithinathan Selvaraju, Jeganathan Ramesh Babu & Thangiah Geetha (2019) Association of
salivary C-reactive protein with the obesity measures and markers in children, Diabetes,
Metabolic Syndrome and Obesity: Targets and Therapy, 12: 1239-1247, DOI: 10.2147/
DMSO.S211624
21. Paqué PN, Herz C, Wiedemeier DB, Mitsakakis K, Attin T, Bao K, Belibasakis GN, Hays JP, Jenzer JS,
Kaman WE, Karpíšek M, Körner P, Peham JR, Schmidlin PR, Thurnheer T, Wegehaupt FJ, Bostanci
N. Salivary Biomarkers for Dental Caries Detection and Personalized Monitoring. J Pers Med.
2021 Mar 23;11(3):235. doi: 10.3390/jpm11030235. PMID: 33806927; PMCID: PMC8004821.
22. Ko TJ, Byrd KM, Kim SA. The Chairside Periodontal Diagnostic Toolkit: Past, Present, and Future.
Diagnostics (Basel). 2021 May 22;11(6):932. doi: 10.3390/diagnostics11060932. PMID:
34067332; PMCID: PMC8224643.
23. Dental caries from a molecular microbiological perspective; Caries Res 2013; 47:89-102; B
Nyvad, W Crielaard, A Mira, N Takahashi, D Beighton
24. Technology development to explore the relationship between oral health and the oral
microbial community; BMC Oral Health 2006, 6: S3; E M Starke, J Smoot, W Liu, D
Chandler, H Lee, D Stahl
25. Adibi SS, Hanson R, Fray DF, Abedi T, Neil B, Maher D, Tribble G, Warner BF, Farach-Carson MC.
Assessment of oral and overall health parameters using the SillHa Oral Wellness System. Oral
Surg Oral Med Oral Pathol Oral Radiol. 2022 Jun;133(6):663-674. doi: 10.1016/
j.oooo.2022.02.007. Epub 2022 Feb 23. PMID: 35393258.
26. Fernando S, Tadakamadla SK, Bakr M, Scuffham PA, Johnson NW. Indicators of Risk for Dental
Caries in Children: A Holistic Approach. JDR Clin Trans Res. 2019 Oct;4(4):333-341. doi:
10.1177/2380084419834236. Epub 2019 Apr 30. PMID: 31039050.
27. Smith JD, Berkel C, Jordan N, Atkins DC, Narayanan SS, Gallo C, Grimm KJ, Dishion TJ, Mauricio
AM, Rudo-Stern J, Meachum MK, Winslow E, Bruening MM. An individually tailored familycentered intervention for pediatric obesity in primary care: study protocol of a randomized type
II hybrid effectiveness-implementation trial (Raising Healthy Children study). Implement Sci.
2018 Jan 15;13(1):11. doi: 10.1186/s13012-017-0697-2. PMID: 29334983; PMCID: PMC5769381.
28. Park SE, Donoff RB, Saldana F. The Impact of Integrating Oral Health Education into a Medical
Curriculum. Med Princ Pract. 2017;26(1):61-65. doi: 10.1159/000452275. Epub 2016 Oct 6.
PMID: 27721313; PMCID: PMC5588329.
29. Nazir MA, Izhar F, Akhtar K, Almas K. Dentists' awareness about the link between oral and
systemic health. J Family Community Med. 2019 Sep-Dec;26(3):206-212. doi: 10.4103/
jfcm.JFCM_55_19. PMID: 31572052; PMCID: PMC6755758.
30. AMA J Ethics. 2016;18(9):941-949. doi: 10.1001/journalofethics.2016.18.9.pfor1-1609.
31. Baker SD, Lee JY, Wright R. The Importance of the Age One Dental Visit. Chicago, IL: Pediatric Oral
Health Research and Policy Center, American Academy of Pediatric Dentistry; 2019.

Dr. Boyd Simkins, DDS
Boyd Simkins is a pediatric dentist with a private practice in North Ogden, Utah. He has been in private practice for 18 years and is Faculty in the Post-doctoral Pediatric Dental Residency at Primary Children's Medical Center in Salt Lake City. His passion in dentistry is improving the health of every child he and his team come in contact with and bridging the gap between medicine and dentistry for the next generation of providers